Job Description

General Summary

Under direct supervision ensures charges are coded appropriately from the medical record as necessary and are entered into the billing system accurately.   May code medical records for surgical practices utilizing ICD-9/ICD-10-CM diagnosis and CPT-4 coding conventions   Assigns specified codes to medical diagnoses with some coding of specific clinical procedures. 

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification.  They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

Deciphers operative reports and other physician medical record documentation to appropriately select codes and maximize charge capture. Ensures coding compliance with established standards and guidelines

Acts as liaison between the clinical and billing departments. Answers questions from billing in a timely manner

Responsible for ensuring quality, accuracy and timeliness of clinical data contained in patient’s medical record by reviewing and analyzing medical information provided by physicians for reimbursement, statistical and indexing purposes

Meets established productivity and proficiency standards

Attends coding seminars, hospital and departmental meetings as required or assigned. Actively participates in hospital educational in-services

Utilizes appropriate customer relation skills to ensure all customers are treated with respect and dignity and that the confidentiality of their data is upheld